Role of Whole-Spine Screening Magnetic Resonance Imaging Using Short Tau Inversion Recovery or Fat-Suppressed T2 Fast Spin Echo Sequences for Detecting Noncontiguous Multiple-Level Spinal Tuberculosis

Study Design Retrospective review. Purpose The purpose of the present study was to evaluate the role of whole-spine screening using short tau inversion recovery (STIR) or fat-suppressed T2W fast spin echo (FSE) sequences in patients with spinal tuberculosis (TB). Overview of Literature The identification of noncontiguous multiple-level spinal tuberculosis (NMLST), symptomatic or not, is important because of its management implications. Most centers do not perform routine whole-spine magnetic resonance imaging (MRI), and the reported incidence of NMLST varies from 1.1% to 74.1%. Methods We completed a retrospective review of clinical and radiographic data of 365 patients with spinal TB who presented at Jawaharlal Nehru Medical College, Aligarh over 5 years. The final analysis included 187 patients who full filled the inclusion criteria, consisting of availability of whole-spine MRI and confirmation of vertebral TB. Diagnosis of NMLST was considered when other vertebral lesions were identified in addition to the primary vertebral disease, with the lesions separated by at least one normal spinal segment. The primary site was defined as the site for which the patient had been referred for MRI. Results NMLST was identified in 47 of 187 patients investigated using whole-spine MRI. The incidence was 25.1%, which was higher than that in earlier reports where whole-spine MRI was not routinely performed. The lumbar spine was involved in 37 patients, thoracic spine in 25, cervical spine in 16, and sacrum in five patients. Combined lumbar spine and thoracic spine involvement was observed in 19 patients. Thirteen patients had lumbar and cervical spine involvement, nine had thoracic and cervical spine involvement, four had combined lumbar and sacral spine involvement, and the remaining two had thoracic and sacral spine involvement. Conclusions Tubercular spondylitis may affect the spine at multiple noncontiguous sites with the majority of additional affected sites remaining asymptomatic. Routine whole-spine MRI using all recommended sequences is not cost-effective and hence not feasible. Therefore, we recommend whole-spine screening using STIR or fat-suppressed T2W FSE sequences in all patients with suspected spinal TB. This screening is cost-effective compared with full-protocol MRI and detects additional cases of NMLST over conventional practice

A Standardized Ultrasound Scoring System for Preoperative Prediction of Difficult Laparoscopic Cholecystectomy

Purpose: Laparoscopic cholecystectomy (LC) has become the treatment of choice for cholelithiasis. Still some patients required conversion to open cholecystectomy (OC). Our aim was to develop a standardized Ultrasound based scoring system for preoperative prediction of difficult LC. Methods and materials: Ultrasound findings of 300 patients who underwent LC were reviewed retrospectively. Four parameters (time taken, biliary leakage, duct or arterial injury, and conversion) were analyzed to classify LC as easy or difficult. The following ultrasound findings were analyzed: GB wall thickness, pericholecystic collection, distended GB, impacted stones, multiple stones, CBD diameter and liver size. Out of seven parameters, four were statistically significant in our study. A score of 2 was assigned for the presence of each significant finding and a score of 1 was assigned for the remaining parameters to a total score of 11. A cut-off value of 5 was taken to predict easy and difficult LC. Results: 66 out of 83 cases of difficult LC and 199 out of 217 cases of easy LC were correctly predicted on the basis of scoring system. A score of >5 had sensitivity 80.7% and specificity 91.7% for correctly identifying difficult LC. Prediction came true in 78.8% difficult and 92.6% easy cases. US findings of GB wall thickness, distended GB, impacted stones and dilated CBD were found statistically significant. Conclusion: This indigenous scoring system is effective in predicting conversion risk of LC to OC. Patients having high risk may be informed and scheduled appropriately and decision to convert to OC in case of anticipated difficulty may be taken earlier

Long-term outcomes of transcutaneous retrobulbar amphotericin B in COVID-19-associated mucormycosis

Purpose: To describe the long-term outcomes of transcutaneous retrobulbar amphotericin B (TRAMB) in COVID-19-associated mucormycosis. Methods: In total, 18 cases of COVID-19-associated mucormycosis were reviewed. In addition to the recommended treatment protocol, all patients were to be given 3.5 mg/ml/day of TRAMB for five days. Results: Of the 18 patients, 2 presented with stage 3a disease, 13 had stage 3c disease, and 3 patients had central nervous system (CNS) involvement (stage 4a and 4c). In addition to planned retrobulbar doses, five patients were given more while two patients received fewer injections (i.e., <5). At the last mean follow-up of 34.67 (±8.88) weeks, 11 patients were in radiological regression and 4 had stable disease while 2 patients had to undergo exenteration; one mortality was observed because of disease progression. Clinical regression in terms of visual and ptosis improvement was seen in seven and nine patients, respectively. Conclusion: Rhino-orbito-cerebral mucormycosis is a serious condition which warrants an aggressive treatment strategy. In unprecedented situations witnessed recently, TRAMB turned out to be an effective and economical alternative. Though large randomized studies are needed to establish its efficacy, TRAMB still manages to halt progression and salvage the globe in significant number of patients, and hence its use should be encouraged on a case-to-case basis especially in developing countries with limited resources